The Swedish Exception?

Stockholm University & Institute for Futures Studies

It is still too early to determine which national responses to the 2020 coronavirus pandemic worked, and which ones did not. It is not too early to explore the differences in local strategies, as well as the context within which they are set. Much of this seems missing from the debate, even though history, tradition, legal and social norms, and so on, should be expected to matter greatly.

This gap is perhaps most evident in most of the commentary around the Swedish response to the pandemic. Sweden’s approach is getting a great deal of attention, in part because it is often framed as going against the mainstream. The differences may be overstated but they certainly exist. They are also instructive for everyone who cares about how best to deal with the crisis.

Sweden’s democratic system of government has a more pronounced epistocratic element than other comparable countries. The term means, roughly, rule by experts. By law and by tradition, Swedish politicians can’t tell the various government agencies what to do, and agencies count relatively few political appointees among their staff. This means that many of the day-to-day decisions relating to government business are made by staff hired on the basis of domain-relevant expertise, rather than political connections. “Ministerial rule” is expressly forbidden.

In the case of COVID-19 strategy, this means that many of the day-to-day decisions are made by staff epidemiologists at the Folkhälsomyndigheten (FHM), the Swedish Public Health Agency. In other countries COVID-19 policy is often developed and announced by politicians, with expert input as they see fit. In Sweden, policy is set by a panel of experts and typically announced by the chief epidemiologist, Anders Tegnell, or his deputy. The latter have therefore, to a great extent, become the face of the government during the crisis.

Critics have charged that Tegnell is overstepping his boundaries and that politicians have allowed themselves to be sidelined. These charges reflect a misunderstanding of Sweden’s constitutional framework. These people are just doing their jobs. Other critics claim that Sweden is going against the recommendations of the experts. This is plainly false: the people who call the shots here are in fact experts. (It is true that Swedish experts disagree, just as they do in other countries)

The Swedish strategy follows a playbook that’s been available online since December last year. The document is in Swedish, but the references are mostly to international, English-language literature. The playbook notes (pp. 20–21) that the only tools available during the early stages of a pandemic are “non-medical” interventions; handwashing, self-isolation, school closures, etc. A literature review performed by the FHM concludes that context matters, but that on the whole the evidence for the effectiveness of most non-medical interventions is weak. Only handwashing and face masks have been evaluated with randomized controlled trials, they say, and even then, the effectiveness has been found to be limited.

The Swedish constitution lacks a provision which allows for the proclamation of a state of emergency in peacetime. Elsewhere, governments may in a crisis suspend rights and freedoms by declaring a state of emergency. The Swedish government does not have this option. It could cordon off specific hotspots to restrict movement, but outside of such areas people still have a constitutional right to move around the country. As Mark Klamberg of Stockholm University puts it:

“Sweden has chosen a rule-of-law approach as opposed to an approach where the Sovereign (i.e. the government) is totally unrestrained in time of crisis.”

Critics who deplore Sweden’s so-called lax approach to COVID-19 do not seem to understand that this approach is to a great extent determined by fundamental constitutional constraints.

Fundamental rights and freedoms cannot easily be restricted, so the Swedish strategy is largely spelled out as official “recommendations”. In terms of normative force, these fall somewhere between advice and law. The education system operates as usual, although schooling for those aged 16-18 years and universities have switched to online instruction. People with symptoms of infection, older people, and people at higher risk for severe illness are encouraged to self-isolate. Everyone is expected to work from home if possible. Compliance with recommendations is high, but far from universal. The Stockholm metro can be completely empty during rush hour, and intercity travel during the long Easter weekend was down about 90% compared to the previous year. That said, some people are still out and about, shopping with abandon or enjoying themselves in outdoor cafés.

The central rationale for the Swedish approach is that harsher measures (border closures, school closings, total lockdowns, etc. ) would be ineffective from a public-health standpoint. Consistent with the playbook, FHM argues that there is little solid evidence for the claim that harsher measures would do any good at this stage of the outbreak. They are not trying to prevent harms to the economy by sacrificing public health, as some appear to believe. That sort of trade-off would be outside of the FHM bailiwick. That said, because the FHM is a public-health agency, it is required to take action with a view to improving public health more broadly conceived; not just to minimise COVID-19 related death.

In addition, the Swedish approach is evidently motivated by behavioral considerations. Tegnell has emphasized that a strategy needs to be sustainable in order to be successful; people have to be able and willing to comply with restrictions and recommendations for as long as necessary. The assumption is that people would be unwilling to put up with sharper restrictions for long enough.

Similarly, the authorities are well aware of the fact that harsher measures can backfire. Obviously no policy, no matter how draconian, will have 100% compliance. And it is not obvious that stricter regulations would increase compliance. From the viewpoint of behavioural science, it is well known that sanctions of various kinds – bans, mandates,incentives – can backfire. Swedish public debate reflects this insight. A bicycle-helmet mandate has been discussed for decades but consistently rejected on the basis that the law would backfire. Note that this does not deny that wearing a bike helmet is a good thing in an accident. It is just recognising that there are better ways to get people to wear helmets than to mandate them.

Mandates can backfire.

The same is true of harsher measures to effect physical distancing. Physical distancing is widely recognised as a good thing; there is disagreement about how best to get people to exhibit the behaviour. Due to this explicit behavioural perspective, it is perhaps not surprising that Tegnell has used the language of nudging to describe, and maybe justify, his agency’s strategy.

Will the strategy be successful? No one can yet know. In addition, the answer will depend on the measure of success. At the time of writing (two months after the first detected European cases of COVID-19) Sweden is doing worse that the other Nordic countries in terms of per-capita fatalities related to COVID-19, but better than many EU countries on the continent, including Belgium, the Netherlands, and the UK. Sweden’s healthcare system is operating as usual, intensive-care units are not (yet) at capacity, and principles of triage have not changed.

There is a lot of active disinformation, and more or less misleading representations of Swedish statistics in circulation. Some of this seems to reflect ignorance about Swedish conditions. Some seems driven by various preconceptions. Official statistics, updated once a day, are available online.

Many people are dismissing the Swedish approach as an ‘experiment’. The rhetorical force of this move is to make the approach sound vaguely threatening and unethical, since human-subjects research normally requires ethics review, informed consent, etc. But there’s no sense in which the Swedish approach is more of an experiment than that of any other country. Everyone’s operating under conditions of risk and uncertainty in this crisis. An approach doesn’t become any more or less of an experiment because everybody else is trying it at the same time, although herd effects may make it feel that way. (For the avoidance of doubt, FHM action is not ‘research’ under Swedish law and does not require ethics review.)

It is important to recognise that the approach cannot be assessed until after the pandemic has subsided, the temporary measures lifted, and the risk of resurgence somehow controlled. One argument against harsher measures is that they merely postpone the outbreak. Another argument, as we have seen, is that harsher measures are unsustainable for any extended period of time. Will countries who chose stricter policies be able to sustain them for the requisite period of time and then lift them without seeing a surge in cases? If yes, that would support the case for harsher measures. If no, it will undercut it. We won’t know the answer until after this is over.

It is also worth noting that not all differences in outcome can be explained in terms of differences in policy. To some extent outcomes are determined by sheer good or bad luck. Sweden was hit hard partly because Swedes love skiing in the Italian Alps, and the populous Stockholm region was on spring break during a critical window when the coronavirus had already spread widely in Northern Italy but before the gravity of the situation was fully appreciated. Two other relatively populous regions, Malmö and Gothenburg, had their spring break earlier and currently have much lower mortality numbers than Stockholm.

With the benefit of hindsight all countries may identify ways in which their policymakers could have intervened more effectively. For Sweden, the FHM should have been more aggressive in identifying and isolating people who came back from spring break in the Italian Alps. They should have worked more actively with stopping the spread to retirement homes. They should have realised that linguistic and other issues can reduce compliance in immigrant communities. Some of the FHM recommendations are needlessly complicated, and could be simplified. The FHM could have been more transparent with how they reached their conclusions, and they could communicate more actively with the community of relevant scholars in Sweden. The Swedish government could have increased testing ability earlier and started testing random samples of the entire population sooner.